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(Circulation. 2003;108:60.)
© 2003 American Heart Association, Inc.

Clinical Investigation and Reports

Surface Electrocardiographic Characteristics of Right and Left Atrial Flutter

Andres Bochoeyer, MD^*; Yanfei Yang, MD^*; Jie Cheng, MD, PhD; Randall J. Lee, MD, PhD; Edmund C. Keung, MD; Nassir F. Marrouche, MD; Andrea Natale, MD; Melvin M. Scheinman, MD

From the Cardiovascular Research Institute and Section of Cardiac Electrophysiology (A.B., Y.Y., R.J.L., M.M.S.), University of California, San Francisco; Texas Heart Institute, St Luke’s Episcopal Hospital, Houston, Tex (J.C.); the Veterans Affairs Medical Center (E.C.K.), San Francisco, Calif; and the Section of Cardiac Electrophysiology (N.F.M., A.N.), Cleveland Clinic Foundation, Cleveland, Ohio.
*Drs Bochoeyer and Yang are co-first authors.

Correspondence to Melvin M. Scheinman, MD, Cardiac Electrophysiology, University of California, San Francisco, 500 Parnassus Ave, MU E 4S, Box 1354, San Francisco, CA 94143-1354. E-mail scheinman{at}medicine.ucsf.edu

Background— There is little information about the surface expression of non-cavotricuspid isthmus (CTI)-dependent right atrial (RA) or left atrial (LA) flutter circuits.

Methods and Results— We retrospectively evaluated 32 episodes (in 26 patients) of atypical RA and 22 episodes (in 21 patients) of LA flutter. The surface ECG of 13 patients with lower-loop reentry was similar to that of their pattern during counterclockwise (CCW) CTI atrial flutter (AFL), except for decreased amplitude of the terminal forces in the inferior leads. In 11 of 24 episodes characterized by high or multiple breaks over the crista, the ECG showed changes that depended on the initial activation sequence of the LA. In 7 of 8 episodes of upper-loop reentry, the ECG pattern completely mimicked that for clockwise (CW) CTI AFL. All 11 patients with an LA septal circuit showed a typical ECG pattern characterized by prominent forces in lead V₁ with flat deflections in the other surface leads. Eleven patients with other LA circuits had a more variable pattern but showed decreased voltage in the inferior leads compared with that of a group with CCW-CTI AFL (1.6±1 vs 2.68±0.7 mV, respectively; P<0.05).

Conclusions— The RA surface-ECG patterns different from those of CCW or CW-CTI could still be CTI dependent. In contrast, a typical CW-CTI surface pattern was always seen in patients with upper-loop reentry, which was non-CTI dependent. LA AFL circuits had either flat or low-amplitude forces in the inferior leads.

Key Words: electrophysiology • atrial flutter • mapping • catheter ablation

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